The Doctor Will See You, Anytime

Drs. Brad Lerner, left, and Louis Cohen traded their own private practices for LernerCohen Healthcare, their shared concierge service. Cohen says he now cares for 300 patients instead of 4,200 and has more time for each. Staff Photo / Rob Mattson

At his former medical practice, Dr. Carlos Caballero was working 14 hours a day, five days a week, and the occasional weekend. He had about 4,000 patients and saw 25 to 30 of them a day, with his two physician assistants seeing the same number. "I was working harder then, and I was terrified," he said. "Your drive home is sitting there thinking, 'Did I do everything I was supposed to do?'"

He is hardly slacking now. He works seven days a week, including 12-hour weekdays and two to four hours on weekends. But he seems considerably more relaxed, sitting on a sofa in an elegant side room at his medical offices during a midday break from seeing patients. Today he will see a half-dozen patients, spending an hour to 90 minutes with each, and take phone calls from several others.

"It allows me to work better," Caballero said. "I think they're getting better attention." Welcome to the world commonly called concierge medicine, boutique medicine or, as its practitioners now prefer, "direct practice." In it, doctors essentially swap a high-volume, low-margin world for just the opposite.

A study by the Government Accountability Office in 2005 is still the definitive look at the style of practice. The agency found concierge physicians take on far fewer patients, typically less than 400, and each patient pays an annual fee, usually $1,500 but as much as $15,000, in return for unlimited access to the doctor. The result is guaranteed revenues of at least a half-million dollars a year, and far more in wealthier areas where residents can afford higher prices.

The combination of less stress and more stable income proves alluring. While only a handful of the country's doctors have gone to direct practice, their numbers have grown rapidly. There are about 500 such doctors across the country, reports the Society for Innovative Medical Practice Design, which began as the American Society of Concierge Physicians. That represents a tripling from 2004, when the GAO found only 146 in its study.

The agency traced the trend's origin to MD2, a Seattle medical practice that opened in 1996, founded by the former team doctor of the city's Supersonics basketball team. Most of the practices are clustered around affluent areas: GAO found the biggest clusters in Seattle, Boston and West Palm Beach.

Caballero was Sarasota's first direct practice. He opened Private Physician Services in October 2001. He has since added a partner. Two years ago, two of Sarasota's most respected doctors -- and members of two of its dominant practices -- opened their own boutique practice. "We jumped at the opportunity, and haven't looked back since," said Dr. Louis Cohen, partner with Dr. Brad Lerner in LernerCohen Healthcare.

Others probably will follow. Doctors of at least two Sarasota practices have told patients or colleagues that they are considering charging patients an annual retainer. Both said that they have not made a final decision. But there are powerful draws for the direct-practice approach: Fewer hassles, lower overhead, and certainly more money.

A doctor's viewAt his old practice, Cohen would start his day at 6:30 a.m. with hospital rounds, see patients in his office from 9 a.m. to 5:30 p.m., and at night sometimes be the lone doctor on call for his group's 50,000 patients. "Controlled bedlam," he said. "Was it the best way to deliver medicine? No, I think absolutely not. Was it a necessity of the way medicine is practiced nowadays? Yes." Now he cares for 300 patients instead of 4,200. That day he had five scheduled appointments, which allowed him to spend more time with each. The smaller patient load also gives doctors more access to each person.

"We feel that allows us the ability to be there anytime the patients need us, whether it be for a house call, for a nursing home visit, an office visit, to give them the level of service that they want," Lerner said. With the added attention comes special services. Caballero's Private Physicians Services and LernerCohen both have dietitians on staff and draw blood in their offices, services often handled at labs or hospitals. The style benefits the doctors, too, in more ways than just reduced stress. By having patients pay up front, they are essentially a cash business. They do not have to haggle with insurance companies or government programs like Medicare or Medicaid. That means they can save money -- at least $100,000 per year -- on bookkeeping-type expenses.

They also likely make more money, by setting their own rates instead of accepting declining reimbursements from Medicare and private insurers. LernerCohen's prices range from $2,800 a year to $5,800 a year. Patients over 80, who they found required much more time, pay the highest rates. Caballero's existing patients pay $2,500 to $4,000 per year, with those 65 and over paying the higher rate. Both practices have held prices constant for existing patients, in part by charging a higher rate for newcomers; Caballero's is $7,500.

Doctors know the financial structure is both advantage and drawback. "The only thing negative I can see about what we're doing is that everybody doesn't have the opportunity to participate," Lerner said. "This is a luxury item and it costs money like a luxury item. Not everybody can afford the cost of this kind of service, and insurance companies won't pay for this type of service."

LernerCohen and other concierge practices urge patients to maintain their insurance or Medicare coverage. Medicare does not pay for concierge physicians' fees, and by law the doctors cannot "double-dip" by billing Medicare. Concierge physicians' fees cover only the primary doctor's services and pay neither for specialists nor for hospitalization. But multiply fees by patients, and a concierge practice can easily generate $1 million or more in revenue a year. That has drawn scrutiny from the American Medical Association and the ire of some doctors.

Another doctor's viewDr. Randy J. Silverstine has worked 60- to 80-hour weeks in Sarasota since 1982, earning incomes in the low six-figure range, he said. His patients have included cabdrivers, professors, retired doctors -- and, lately, many people who could no longer afford their doctors, he said. So he views concierge medicine and its potential million-dollar revenues as "unprofessional, unethical and a spectacular show of greed," he said. "It's wanting to work less and make a phenomenal amount of money," he said. "It's not a solution for health care in this country. It's health care for the rich and famous."

Those questions have swirled around concierge medicine almost since its outset, and practitioners are well aware. In 2001, the American Medical Association voted to study the issue, and its Council on Medical Service returned with the same answer: "A multitiered system of care already exists in the United States." The council saw no ethical problems with the concierge approach, pointing to established AMA policies that say doctors have the right to set up their practices as they want, and charge a fair fee established in a patient contract.

It also said there was "no evidence that special physician-patient contracts, such as retainer agreements, adversely impact the quality of patients' care or the access of any group of patients to care." In fact, the council said the issue was overblown. "It would appear that the amount of media coverage devoted to the subject has been disproportionate," the report said. But it did cite what it termed "risks" associated with concierge medicine: that smaller patient loads might dull a doctor's skills, and that doctors switching to a high-fee practice might leave some patients without care.

That was at the heart of Silverstine's lament.

"After developing real, meaningful, beautiful, caring relationships with many patients and their families, how do you turn around and demand they now begin paying 5 to 10 thousand dollars per head?" he asked. "Just because something has a price doesn't mean it's right, doesn't mean that it works or it's good for the profession or for the patients."